Mental-Health-Related Admissions to the Acute Medical Unit During COVID-19

Clinical Medicine Publish Ahead of Print, published on December 18, 2020 as doi:10.7861/clinmed.2020-0635

COVID-19 RAPID REPORT Clinical Medicine 2020, Vol 21 No 1 January 2021

Mental-health-related admissions to the acute medical unit during COVID-19

Authors: Ben GrimshawA and Ella ChaudhuriB

During COVID-19 there has been increased pressure on mental Table 1. Number of cases at each stage of the search health services internationally. In this report, we compare strategy admissions to one acute medical unit (AMU) for patients with mental health problems during the COVID-19 pandemic (April, Year Month Total Cases Mental- May and June 2020) to the same period of time in 2019. We number found by health-related ABSTRACT found an increase in this cohort of patients in 2020, both as of AMU search admissions an absolute number and as a proportion of the medical take. attendances strategy (on clinical We outline some strategies which we have adopted locally to review) improve care for this patient group. 2019 April 1,993 167 22 KEYWORDS: acute medicine, mental health, AMU, COVID-19 May 1,957 172 31 DOI: 10.7861/clinmed.2020-0635 June 1,910 148 15

Total 68 Introduction 2020 April 876 82 27 The global COVID-19 pandemic has increased strain on the mental health of individuals and on the delivery of mental health services May 900 81 38 to support those with pre-existing mental illness.1,2 Studies have also June 1,180 99 41 highlighted the effects on the mental health of healthcare workers.3 There has been national recognition of these problems, with attempts Total 106 at mitigation.4 However, as the situation has evolved, it has become clear that an increased proportion of our work on the AMU involves AMU = acute medical unit managing mental health problems and their physical consequences. Here we quantify the increase in mental-health-related admissions not considered in this analysis. The following search terms were compared to the same period of time in 2019. We also highlight applied to each dataset: ‘poisoning’, ‘mental and behavioural strategies we have adopted locally to improve care in this cohort of disorder’, ‘anorexia’, ‘visual’, ‘hypokalaemia’ and ‘observation’. patients and promote the safety and wellbeing of our staff. These search terms were predicted to best capture deterioration in pre-existing mental health conditions and the physical Methods consequences of mental illness. Cases were drawn from both primary diagnosis and primary diagnosis chapter data entries. Local Qlik Sense data, conforming to national clinical coding Duplicate cases (identified by hospital number) were deleted. Case standards, are recorded for all patients admitted to the AMU. notes were reviewed for each highlighted care episode to ensure the Patient-level data from April, May and June 2019 and 2020 were clinical presentation was related to mental health. analysed. ICD-10 codes for all patients were reviewed. A search strategy was devised to capture ‘mental-health-related admissions’ – defined as patients who were referred to, or discussed with, our Results mental health liaison team in relation to the presenting complaint. The number of cases identified at each stage of the search strategy Patients who developed psychiatric symptoms as inpatients were is shown in Table 1. Despite the decreased total number of acute medicine attendances in 2020 compared to 2019, the number of Authors: Aconsultant in acute medicine and stroke, North Bristol NHS confirmed mental-health-related admissions remained high. Trust, Bristol, UK; Bconsultant in acute medicine, North Bristol NHS Trust, The number of mental-health-related admissions confirmed on Bristol, UK clinical review was plotted against date for April, May and June in

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Fig 1. Cumulative Mental-health-related admissions plotted against time (2019 and 2020).

2019 and 2020 (Fig 1). This shows the number of mental-health- referred to AMU. This may be confounding a comparison of 2019 related admissions to the AMU for April and May was similar in and 2020 patient numbers. However, this reconfiguration has been both 2019 and 2020, despite a marked decrease in total number of in place since 1 April 2020 and does not explain the sustained rise in AMU attendances in 2020. In June 2020 the number of admissions patients attending with mental health problems through April, May related to mental health increased compared to June 2019 (Fig 1). and June 2020. The number of mental-health-related admissions was plotted as The total number of monthly admissions to our AMU has decreased a proportion of the total number of admissions to AMU (Fig 2). markedly during the COVID-19 pandemic. Despite this, the number of This shows an increase in these admissions as a proportion of the admissions relating to deteriorating mental health continues to rise. medical take for 2020 compared to 2019. Factors driving this increase are beyond the scope of this work, but The total number of mental-health-related admissions was plotted possibly include interruption to local delivery of mental health support for April, May and June 2019 and 2020.2019 This shows an increase in services, telephone consultations2020 replacing face-to-face appointments the total number of these admissions in 2020 compared with 2019 and support group work taking place via remote access (or being for each month analysed (Fig 3). cancelled altogether). Anxiety and ‘reactive’ mental disorders in the The incidence of mental-health-related admissions over each context of COVID-19 may also play a role. 3-month study period increased from 0.9 cases per 1,000 person Within AMU, this cohort of patients can present specific years in 2019 to 1.4 cases per 1,000 person years in 2020. challenges. Even a small increase in the number of mental-health- The proportion of mental-health-related admissions in each search related admissions can have large implications. Increased medical category was plotted for 2019 and 2020. This shows a broader range of and nursing staff time is typically required to manage patients Mental-health-relatedisnin presentations in enal 2020 compared and ehaiural to 2019 disrder (Fig 4). with Anreia mental health isual admissions smms who are alaemia exhibiting escalating behaviour. This circumstance may require verbal de-escalation Discussion techniques. In some cases input from hospital security is necessary, along with rapid tranquilisation supervised by medical staff. The number of mental-health-related admissions to our AMU has Similarly, complex capacity and assessments under the Mental increased in 2020 compared to 2019. There has been an increase Health Act are time consuming, requiring an in-depth exploration in both the absolute number of admissions and admissions as a of patient comprehension and understanding. There is a risk that proportion of the overall medical take. These observations have patients may harm themselves (or others) while under our care and, been made during the COVID-19 pandemic and support the work of when this does occur, more time is required to support staff and other groups which suggest that COVID-19 is a significant stressor.5 analyse the root cause of any episode of harm. There is an effect A potential limitation of this analysis is that duplicate data entries, of stress on staff, with a requirement to debrief after difficult or based on hospital number, were deleted as part of the search dangerous situations. strategy. This was done to ensure cases were not double-counted (because data was drawn from two different coding data series). Local measures taken However, if a single patient attended more than once, only one admission would be included in the analysis. This could have led to In order to address these issues, we have implemented several an underestimation of the number of mental health cases recorded changes in our local practice. above – though the conclusion of an increasing number of cases in As of June 2020, we have been using a mental health early 2020 still stands. warning score (MHEWS) for patients who are at risk of deterioration Another potential limitation is that our emergency department in their mental state during an AMU admission. This locally has reconfigured three observation beds into a minor injuries area developed observation tool aims to identify deteriorating patients during the COVID-19 pandemic. Some patients who require a period and trigger an intervention, thus avoiding crisis point. We deliver of monitoring following deliberate self-poisoning are consequently ongoing training for nursing staff in the implementation of this tool. © Royal College of Physicians 2020. All rights reserved. 2

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COVID-19 rapid reports

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umer aiens admied aiens Aril a une Aril a une Fig 2. Mental-health-related admissions as a proportion of the medical Fig 3. Monthly mental-health-related admissions for 3 months in 2019 take for 3 months in 2019 and 2020. and 2020.

2019 2020 umer aiens

Aril a une isnin enal and ehaiural disrder Anreia isual smms alaemia Fig 4. Proportion of patients in each mental health coding category for 2019 and 2020.

We have a designated ligature-free room in an area of high the COVID-19 pandemic. It is possible that this also reflects the visibility for nursing staff in which potentially harmful furnishings experience of other units nationally. It is appropriate, now more (shower rail, hoist tracking, clothes hooks) have also been removed. than ever, to consider how we can deliver high-quality acute medical We have a local rapid tranquilisation policy, developed in care to this vulnerable cohort of patients. conjunction with our psychiatric liaison team. We also have a mental health link nurse (dual trained as a registered nurse References and registered mental health nurse) who has dedicated time to deliver 1:1 training . Sessions can be trainee-led or focused on 1 Torales J, O’Higgins M, Castaldelli-Maia JM et al. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J implementation of our rapid tranquilisation policy. Soc Psychiatry 2020;66:317–20. MAYBO training (a conflict management and physical intervention 2 Ettman C, Abdalla SM, Cohen GH et al. Prevalence of depression course) had been implemented for our2019 staff prior to the pandemic. symptoms in US adults2020 before and during the COVID-19 pandemic. This has now been paused due to social distancing restrictions. JAMA Network Open 2020;3:e2019686. However, we are currently exploring options to restart this training 3 Ng Q, De Deyn MLZQ, Lima DY et al. 2020. The wounded healer: with a mix of reduced class numbers and remote access. A narrative review of the mental health effects of the COVID-19 We encourage debriefs after significant events relating to mental pandemic on healthcare workers. Asian J Psychiatr 2020;54:102258. 4 Mental Health UK. Managing your mental health during the health. These can be ‘hot’ debriefs (immediately after the event) or coronavirus outbreak. https://mentalhealth-uk.org/help-and- ‘cold’ debriefs (at a pre-arranged time). Remote meeting methods information/covid-19-and-your-mental-health/ [Accessed 1 July 2020]. have driven an increased attendance for cold debriefs as staff no 5 Fancourt D, Steptoe A. COVID-19 social study. https://www. longer need to attend in person to contribute. nuffieldfoundation.org/project/covid-19-social-study. Our trust clinical psychologyisnin team hasenal started and a ehaiural course of resilience disrder Anreia isual smms alaemia training with band 6 and 7 nurses on the AMU.

Conclusion Address for correspondence: Dr Ben Grimshaw, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol BS10 Our local data indicate an increase in the number of patients 5NB, UK. presenting to AMU with problems related to mental health during Email: [email protected]